Myself/ My Child to be treated:
Consent: I have been informed of the training level of the treating
chirurgeon(s) and hereby give consent for Myself/ My Child to be treated:
Patient/Guardian Sig:_____________________________________________________
Refusal: I have been informed of the training level of the treating
chirurgeon(s). I understand that first aid has been recommended for Myself/
My child which I refuse. I understand that it is my responsibility to seek
appropriate medical care. I release the chirurgeon(s) and all SCA authorities
from any and all liability for any ill effects that may result from my
decision to refuse aid.
Patient/Guardian Sig:_____________________________________________________
Please Print All Information
Legal Name
Time of incident
Adult
Child
_______________________________________________________________________
SCA Name _____________________________________________________________
Guardian Legal Name______________________________________________________
Address________________________________________________________________
Trauma__________ Illness_________ M__ F___________ D.O.B.__/__ /__
Phone(___ )_________________________ Recurring Injury______ Y___N
Allergies: _____________________________________________________
Medications: __________________________________________________
Medical History: _______________________________________________
Injury Type ______Kitchen_____ Dancing_____ Combat_____ Camping_____Other
If comat: Single Melee
Injured by: weapon Terrain Armor Weather
If from weapon, type SS WS TW BS DGR PA Spear GS Cbt Arch
Rapier Archry Unknown Other
Notes: ______________________________________________________________
If Kitchen injury; type Cut Burn Crush Other
Notes: ______________________________________________________________
____________________________________________________________________
Complaint: ___________________________________________________________
Action Taken: _________________________________________________________
____________________________________________________________________
Advice Given: Ice Rest Fluids See Doctor Other
Attending Chirurgeon(s):
SCA Name
Print Legal Name
Signature
Phone
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
C-I-C: ______________________________________________________________
Vital Signs
Time_________ Respiration _____Pluse ___B/P___ L.O.C. ___R_ Pupils_
L_______________ Temp
Regular
Regular
Alert
Normal
Shallow
Voice
Dilated
Labored
Irregular
Pain
Constricted
______
Unresp Unresp
Time_________ Respiration _____Pluse ___B/P___ L.O.C. ___R_ Pupils_
L_______________ Temp
Regular
Regular
Alert
Normal
Shallow
Voice
Dilated
Labored
Irregular
Pain
Constricted
______
Unresp Unresp
Time_________ Respiration _____Pluse ___B/P___ L.O.C. ___R_ Pupils_
L_______________ Temp
Regular
Regular
Alert
Normal
Shallow
Voice
Dilated
Labored
Irregular
Pain
Constricted
______
Unresp Unresp
Pt. will seek appropriate follow-up care____________ Pt. Transported to facility_______
Where________________________________ By whom________________________
Time left site____________________________ How ___________________________
Comments/Progess/Additional treatment:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Notes/Comments/Addtional Names Relative to report:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Please mail to the Kingdom Chirurgeon with event report form.
THL Robert Marston
1219 Colfax St
Pittsburgh PA 15212